giving evidence of the disease very soon after birth, in cases where the mother had typhoid fever. Griffith in the same paper reported 23 cases of this type. It is an established fact that young infants born of mothers suffering from typhoid fever, may exhibit the Widal reaction without having any clinical symptoms. Morse states that the agglutinating power may be transmitted to the infant through the palcenta, not only during the course of the typhoid fever in the mother, but even when pregnancy has taken place, some time after recovery, and that it may also be transmtited through the milk. Hence, the Widal reaction is less valuable in early infancy, and would not be proof of typhoid without clinical symptoms. Griffith suggests that in these cases the subjects might have had typhoid in utero, or that the agglutinating principle has past from the mother to the child through the placenta. McCrae reports a case where typhoid bacilli were found in the chorion. Of 23 cases of congenital typhoid reported by Griffith there were 19 deaths, and 3 recoveries. It is an interesting fact that postmortems on the congenital cases show an absence of severe intestinal lesions as would be found in adults.

3rd-TYPHOID FEVER IN INFANCY.

Griffith in 1892 collected reports of 139 cases occurring in the first year of life. 52 of these occurred during general epidemics. 77 terminated fatally, 28 recovered, and in 34 the results were not mentioned. It is interesting to learn that one of these cases was reported by W. P. Northrup of New York. This author has charge of the Pathology reports of the New York Foundling Asylum where in 2,000 autopsies, he did not find any with the intestinal lesions of typhoid. In his cases the symptoms were diarrhea, enlargement of the spleen, eruption and positive Widal reaction. During the second year of life, Griffith has collected 187 cases. In this group 69 recovered, 32 died and in 86 the results were not mentioned. He explains the high mortality in these tables upon the theory that only the severe and well marked cases were reported. Since Griffith's very exhaustive report in 1892, typhoid fever has been reported by many writers, so that the theory that infants are immune, is not tenable, and it becomes the duty of the physician to search for this disease at any age. As I have said, typhoid is certainly more rare in infants than in children and adults, and more rare in hospitals than in private practice.

The modes of infection, of course are the same as in adults,

and there are reasons why infants would be less liable to be infected. Breast fed infants, of course, are largely exempt. The heating of the milk in the bottle fed infant, naturally destroys the bacilli, if present in the milk. Also, many cases of typhoid in adults are due to infection from the care of the disease, as nurses and attendants. This is a danger which the infant escapes. On the other hand, the washing of bottles and nipples with unboiled water, is a possible source of infection. An interesting mode of infection as recorded by Bloch in a Paris Hospital where an epidemic of typhoid fever occurred in the Scarlet Fever pavilion. It was found that children had been bathed in one tub, and the same cloths had been used for several patients. From the pus from the vagina of two or these patients, typhoid bacilli and gonococci were obtained. It was presumed that the bacilli were conveyed from one child to the other by the clothes or bath water and then carried to the mouth by the hands, and 52% of the children so exposed contracted typhoid fever.

The symptoms of typhoid in children do not differ from those in adults, and that phase of the subject has already been thoroughly covered by Dr. Before speaking of the symptoms in infants, I wish briefly to report three cases:

1st. Kathryne B., age 41⁄2 years. Taken sick in August, 1910. Diagnosis made at the end of week because of enlarged spleen and rose colored spots. Widal test positive. Beginning of third week developed delirium and opisthotonus. Case seen by Dr. Aikin. These symptoms subsided, fever persisted, and the fifth week developed severe pain in the left leg followed by swelling and an enormous abscess on the inner side of the thigh. near the knee. This was opened and drained and the wound closed in the tenth week of the disease. Emaciation extreme, recovery complete, and at this writing child entirely well.

2nd. Dorothy W., age 5 years. Spent one week in Iowa in January. Returned home. Was taken sick. Typhoid fever diagnosed. Taken to M. E. Hospital February 3rd. Nothing unusual until February 7th when there developed a severe. ulcerous stomatitis. This gradually grew worse and in the morning of February 10th there was a general edema of the face and neck and the patient died in the afternoon. There were no other complications. The urine gave the diazo test with the presence of indican and a trace of albumin. I cite these two cases to show that complications may occur in children equally as severe as in adults.

3rd. Baby Fish. Jewish parents with unhygienic environments. Infant age 16 months. Taken sick suddenly. Temperature 105. General convulsions. I thought it a case of intestinal sapraemia and gave the routine treatment of calomel and oil. The next day found the bowels had moved freely, but the temperature was 104. Child lay in a stupor and there was certainly decided rigidity of the muscles of the neck. I naturally thought of meningitis. Next three days temperature still 104. Decided opisthotonus, delirium. Did a lumbar puncture but the fluid was entirely clear. 4th day opisthotonus less marked. Fever 102 and I thought the meningeal symptoms due to irritation. I made no visit to the child until the seventh day. At this visit for the first time I discovered some enlargement of the spleen and a few scattered rose colored spots. This was my first hint that it might be typhoid fever. I sent a sample of the blood to the City Laboratory and received the report that Widal test was positive. The spleen continued to enlarge, more spots appeared and the third week of the disease, the child had a severe intestinal hemorrhage. After this made an uneventful recovery. The case illustrates the difficulty of an early diagnosis.

DIAGNOSIS.

Except in the presence of an epidemic, the diagnosis cannot be made until at least the end of the first week. In my personal experience, I have confused typhoid fever with the following diseases:

1st. General maliary tuberculosis. In that case I knew nothing of the previous condition of the child and found it with an irregular fever and diarrhea. When these symptoms continued after clearing out the bowels, I thought of typhoid. When at the end of the week I could find neither rose colored spots nor enlarged spleen, I decided that I had made an error in the diagnosis. Fatal result.

2nd. Tubercular Meningitis. Many of these cases begin with slight fever, vague pains and for some days closely simulate typhoid.

3rd. Cerebro Spinal Meningitis. I have cited one case begining acute and simulating this disease. Central pneumonHere were have the fever, often delirium and the absence of the local lung symptoms for some days. The one clinical symptom that might throw light on this class is the increased rate of respiration.

4th. Intestinal Infections. In these cases we often have fever, diarrhea, anorexia and for some days may naturally suspect typhoid. In all of these conditions the Widal test does not aid us until at least the end of the week. In some the blood count will render decided help. Examination of the faces for Elberths bacilli requires complete laboratory and several days time for making of cultures. The same is true of the examination of the urine. Two clinical symptoms of most value are the enlarged spleen and the rose colored spots. "Especially a succession of crops of papulo macular rose pink spots distributed over the upper abdomen or lower thoracic regions disappearing on pressure or when the skin is made tense, each spot fading in the course of three or four days. This does not occur in any other febrile infection and may be regarded as rendering a provisional diagnosis positive." The enlarged spleen is ever constant and not only that, but the progressive enlargement of the spleen. These two symptoms when associated with fever establish the diagnosis clinically. In the absence of these symptoms a positive Widal test should be evidence of atypical typhoid.

The treatment of typhoid fever in infants will be along the same general lines as those already indicated by the previous writer. Infants do not bear baths well, and sometimes do not react even to cold sponging. Their diet requires special Milk frequently tends to produce constipation.

care.

CONCLUSIONS.

1st. The foetus may be infected in utero by the typhoid bacilli.

2nd. The infant may be born at full term normal and develop the clinical symptoms of typhoid within a few days, as a result of infection through the placenta.

3rd. The infant's blood may respond to the Widal test without it having any evidence of the disease.

4th. Infants under two years are relatively immune to typhoid.

5th. Infants under two years are less liable to be infected by typhoid, than children or adults.

Anti-Typhoid Inoculation.

*By JOHN MONRO Banister, A. B., M. D. (Colonel, U. S. Army, Retired) Omaha.

It is now thoroughly recognized that typhoid fever is a bacteriemia. Infection takes place through the gastro-intestinal tract, the foci of infection being the lymphoid tissue in which the digestive tract is so rich. From this tissue, which furnishes ideal conditions for their development, the bacilli find an easy entrance into the blood stream, and are then distributed throughout the body. They do not multiply in the blood stream, however, but in the bone marrow, spleen, and mesenteric glands, whence they are discharged in countless millions into the circulation. The toxin produced by the micro-organisms is not soluble in the blood, but is contained in the bacillary structure itself.

It is an established fact that an attack of typhoid fever will confer a marked degree of immunity against further seizure, and hence it would seem that any method by which it might be possible to establish an artificial immunity through the creation of similar anti-bodies would prove a boon to the human race.

It would appear from results obtained during the last few years in the military services of England, Germany and the United States, that we have at hand such a means in the use of anti-typhoid inoculation.

Not only does such inoculation have a marked effect in preventing typhoid fever, but it also seems to have a decided influence in shortening the disease and rendering its course more benign when administered during the attack.

In discussing the subject of anti-typhoid inoculation therefore, I shall treat of it both as a preventive, and as a therapeutic

measure.

1. Anti-typhoid inoculation as a preventive measure:

For the data, which we now possess relative to this means of prevention against one of the greatest of all the ills, which escaped from the fabled box of Pandora, the world is indebted to the military surgeon, just as it is for our knowledge of the protozoan character and method of transmission of the malarial parasite, and of the means of transmission of yellow fever, to mention only two of the debts under which humanity has been placed by the self-sacrificing labors of the members of the medical corps of the armies of civilized nations.

In military campaigns, typhoid fever has long been the

*Read before the Nebraska State Medical Association, Lincoln, May 7-9, 1912.